EP3348305B1 - Schrittmacher für unilaterale stimmband-autoparalyse - Google Patents

Schrittmacher für unilaterale stimmband-autoparalyse Download PDF

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EP3348305B1
EP3348305B1 EP18158874.0A EP18158874A EP3348305B1 EP 3348305 B1 EP3348305 B1 EP 3348305B1 EP 18158874 A EP18158874 A EP 18158874A EP 3348305 B1 EP3348305 B1 EP 3348305B1
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stimulation
subject
muscles
vocal cord
activation
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EP3348305A1 (de
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Werner Lindenthaler
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MED EL Elektromedizinische Geraete GmbH
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MED EL Elektromedizinische Geraete GmbH
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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00—Electrotherapy; Circuits therefor
    • A61N1/18—Applying electric currents by contact electrodes
    • A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
    • A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
    • A61N1/36003—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation of motor muscles, e.g. for walking assistance
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B5/00—Measuring for diagnostic purposes; Identification of persons
    • A61B5/24—Detecting, measuring or recording bioelectric or biomagnetic signals of the body or parts thereof
    • A61B5/25—Bioelectric electrodes therefor
    • A61B5/279—Bioelectric electrodes therefor specially adapted for particular uses
    • A61B5/296—Bioelectric electrodes therefor specially adapted for particular uses for electromyography [EMG]
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00—Electrotherapy; Circuits therefor
    • A61N1/18—Applying electric currents by contact electrodes
    • A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
    • A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
    • A61N1/3605—Implantable neurostimulators for stimulating central or peripheral nerve system
    • A61N1/36053—Implantable neurostimulators for stimulating central or peripheral nerve system adapted for vagal stimulation
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00—Electrotherapy; Circuits therefor
    • A61N1/18—Applying electric currents by contact electrodes
    • A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
    • A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
    • A61N1/3605—Implantable neurostimulators for stimulating central or peripheral nerve system
    • A61N1/3606—Implantable neurostimulators for stimulating central or peripheral nerve system adapted for a particular treatment
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00—Electrotherapy; Circuits therefor
    • A61N1/18—Applying electric currents by contact electrodes
    • A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
    • A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
    • A61N1/3605—Implantable neurostimulators for stimulating central or peripheral nerve system
    • A61N1/36128—Control systems
    • A61N1/36135—Control systems using physiological parameters
    • A61N1/36139—Control systems using physiological parameters with automatic adjustment
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00—Electrotherapy; Circuits therefor
    • A61N1/18—Applying electric currents by contact electrodes
    • A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
    • A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
    • A61N1/3605—Implantable neurostimulators for stimulating central or peripheral nerve system
    • A61N1/36128—Control systems
    • A61N1/36146—Control systems specified by the stimulation parameters
    • A61N1/36167—Timing, e.g. stimulation onset
    • A61N1/36171—Frequency
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00—Electrotherapy; Circuits therefor
    • A61N1/18—Applying electric currents by contact electrodes
    • A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
    • A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
    • A61N1/372—Arrangements in connection with the implantation of stimulators
    • A61N1/37211—Means for communicating with stimulators
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00—Electrotherapy; Circuits therefor
    • A61N1/18—Applying electric currents by contact electrodes
    • A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
    • A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
    • A61N1/372—Arrangements in connection with the implantation of stimulators
    • A61N1/37211—Means for communicating with stimulators
    • A61N1/37217—Means for communicating with stimulators characterised by the communication link, e.g. acoustic or tactile
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00—Electrotherapy; Circuits therefor
    • A61N1/18—Applying electric currents by contact electrodes
    • A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
    • A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
    • A61N1/372—Arrangements in connection with the implantation of stimulators
    • A61N1/37211—Means for communicating with stimulators
    • A61N1/37217—Means for communicating with stimulators characterised by the communication link, e.g. acoustic or tactile
    • A61N1/37223—Circuits for electromagnetic coupling
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00—Electrotherapy; Circuits therefor
    • A61N1/02—Details
    • A61N1/04—Electrodes
    • A61N1/05—Electrodes for implantation or insertion into the body, e.g. heart electrode
    • A61N1/0551—Spinal or peripheral nerve electrodes
    • A61N1/0556—Cuff electrodes
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00—Electrotherapy; Circuits therefor
    • A61N1/18—Applying electric currents by contact electrodes
    • A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
    • A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
    • A61N1/3605—Implantable neurostimulators for stimulating central or peripheral nerve system
    • A61N1/3606—Implantable neurostimulators for stimulating central or peripheral nerve system adapted for a particular treatment
    • A61N1/3611—Respiration control
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00—Electrotherapy; Circuits therefor
    • A61N1/18—Applying electric currents by contact electrodes
    • A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
    • A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
    • A61N1/3605—Implantable neurostimulators for stimulating central or peripheral nerve system
    • A61N1/36128—Control systems
    • A61N1/36146—Control systems specified by the stimulation parameters
    • A61N1/3615—Intensity
    • A61N1/36157—Current
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00—Electrotherapy; Circuits therefor
    • A61N1/18—Applying electric currents by contact electrodes
    • A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
    • A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
    • A61N1/3605—Implantable neurostimulators for stimulating central or peripheral nerve system
    • A61N1/36128—Control systems
    • A61N1/36146—Control systems specified by the stimulation parameters
    • A61N1/36167—Timing, e.g. stimulation onset
    • A61N1/36175—Pulse width or duty cycle

Definitions

  • the present description generally relates to the treatment of unilateral vocal cord autoparalysis, and in particular, to devices and methods for stimulating the recurrent laryngeal nerve (RLN) or the glottic closure reflex of a human subject to treat the autoparalysis.
  • RNN recurrent laryngeal nerve
  • voicing occurs when air is expelled from the lungs through the glottis, creating a pressure drop across the larynx. When this drop becomes sufficiently large, the vocal folds start to oscillate.
  • the minimum pressure drop required to achieve phonation is called the phonation threshold pressure, and for humans with normal vocal folds, it is approximately 2-3 cm H 2 O.
  • the motion of the vocal folds during oscillation is mostly laterally, though there is also some superior component as well. However, there is almost no motion along the length of the vocal folds.
  • the oscillation of the vocal folds serves to modulate the pressure and flow of the air through the larynx, and this modulated airflow is the main component of the sound of most voiced phones.
  • vocal folds will not oscillate if they are not sufficiently close to one another, are not under sufficient tension or under too much tension, or if the pressure drop across the larynx is not sufficiently large.
  • a phone is called voiceless if there is no phonation during its occurrence.
  • voiceless phones are associated with vocal folds that are elongated, highly tensed, and placed laterally (abducted) when compared to vocal folds during phonation.
  • Fundamental frequency the main acoustic cue for the percept pitch, can be varied through a variety of means. Large scale changes are accomplished by increasing the tension in the vocal folds through contraction of the cricothyroid muscle. Smaller changes in tension can be effected by contraction of the thyroarytenoid muscle or changes in the relative position of the thyroid and cricoid cartilages, as may occur when the larynx is lowered or raised, either volitionally or through movement of the tongue to which the larynx is attached via the hyoid bone.
  • fundamental frequency is also affected by the pressure drop across the larynx, which is mostly affected by the pressure in the lungs, and will also vary with the distance between the vocal folds. Variation in fundamental frequency is used linguistically to produce intonation and tone.
  • the voicing mechanism that is specifically designed for voice production is the larynx.
  • the larynx is between the pharynx and the trachea. It communicates with the mouth and the nose though the laryngeal and oral parts of the pharynx. Although the larynx is part of the air passages, the larynx normally acts as a valve for preventing swallowed food and foreign bodies from entering the lower respiratory passages.
  • the larynx is located in the anterior portion of the neck.
  • the laryngeal skeleton comprises nine cartilages that are joined by various ligaments and membranes. Three of the cartilages are single (thyroid, cricoid and epiglottis), and three are paired (arytenoid, corniculate, and cuneiform).
  • the extrinsic muscles of the larynx move the larynx as a whole.
  • the infrahyoid muscles (omohyoid, sternohyoid, and sternothyroid) are depressors of the hyoid bone and the larynx, whereas the suprahyoid muscles (stylohyoid, digastric, mylohyoid and geniohyoid) and the stylopharyngeus are elevators of the hyoid bone and larynx.
  • the intrinsic muscles of the larynx are concerned with the movements of the laryngeal parts, making alterations in the length and tension of the vocal folds and in the size and shape of the rima glottidis in voice production. All intrinsic muscles of the larynx are supplied by the recurrent laryngeal nerve (RLN), a branch of the vagus nerve (CN X) except the cricothyroid muscle, which is supplied by the external laryngeal nerve.
  • RNN recurrent laryngeal nerve
  • CN X vagus nerve
  • the adductors of the vocal folds include the lateral cricoarytenoid muscles which arise from the lateral portions of the cricoid cartilage and insert into the muscular processes or the arytenoid cartilages. These muscles pull the muscular processes anteriorly, rotating the arytenoid cartilages so that their vocal processes swing medially. These movements adduct the vocal folds and close the rima glottidis.
  • the principle abductors of the vocal folds are the posterior cricoarytenoid muscles. These muscles arise on each side from the posterior surface of the lamina of the cricoid cartilage and pass laterally and superiorly to insert into the muscular processes of the arytenoid cartilages. They rotate the arytenoid cartilages, thereby deviating them laterally and widening the rima glottidis.
  • the main tensors of the vocal folds are the triangular cricothyroid muscles. These are located on the external surface of the larynx between the cricoid and thyroid cartilages.
  • the muscle on each side arises from the anterolateral part of the cricoid cartilage and inserts into the inferior margin and anterior aspect of the inferior horn of the thyroid cartilage. These muscles tilt the thyroid cartilage anteriorly on the cricoid cartilage, increasing the distance between the thyroid and arytenoid cartilages.
  • the vocal ligaments are elongated and tightened and the pitch of the voice is raised.
  • the principle relaxers of the vocal folds are the broad thyroarytenoid muscles. They arise from the posterior surface of the thyroid cartilage near the median plane and insert into the anterolateral surfaces of the arytenoid cartilages.
  • One band of its inferior deep fibers, called the vocalis muscle arises from the vocal ligament and passes to the vocal process of the arytenoid cartilages anteriorly.
  • the thyroarytenoid muscles pull the arytenoid cartilages anteriorly, thereby slackening the vocal ligaments.
  • the vocalis muscles produce minute adjustments of the vocal ligaments (e.g., as occurs during whispering). They also relax parts of the vocal folds during phonation and singing.
  • the laryngeal nerves are derived from the vagus nerve (CN X) through the superior laryngeal nerve and the RLN. All intrinsic muscles, except cricothyroid, are innervated by the RLN with fibers from the accessory nerve (CN XI).
  • the external laryngeal nerve supplies the cricothyroid muscle.
  • the supraglottic portion of the laryngeal mucosa is supplied by the internal laryngeal nerve, a branch of the superior laryngeal nerve.
  • the infraglottic portion of the laryngeal mucosa is supplied by the RLN.
  • WO 02/081026 A2 discloses a pacemaker system for a human subject having bilateral vocal cord autoparalysis comprising a sensing electrode configured to detect inspiratory activities of the infrahyoidal muscles or the diaphragm of a human subject, such a stimulation being limited to the in-spiratory phase of respiration, and a processor for receiving a first signal from the sensing electrode and generating a second signal.
  • US 2011/0125212 A1 discloses a hybrid method for modulating upper airway function in a subject for treating laryngeal disorders via synergistic modulation of at least one extrinsic laryngeal muscle and at least one intrinsic laryngeal muscle.
  • the method includes providing a neuromodulation system, which can include an electrode array or a sensor array.
  • the sensor array can include one or more sensors for detecting a physiological parameter of interest.
  • a method for treating a human subject having unilateral vocal cord paralysis includes providing a sensing electrode configured to detect voice activity of the subject and to generate a first signal and generating at least one stimulation parameter, using a processor, in response to receiving the first signal.
  • the stimulation parameter is based on the first signal.
  • the method further includes activating a glottic closure reflex in response to receiving the stimulation parameter.
  • the activating may include electrical stimulation and/or mechanical stimulation.
  • the sensing electrode may be configured to detect electromyographic (EMG) activity of a vocalizing muscle and/or to detect movement related to voice production.
  • EMG electromyographic
  • the sensing electrode may be a microphone that detects acoustic signals related to voice production, may be an impedance sensor that detects changes of impedances related to voice production, and/or may be a pressure sensor that detects changes in pressure related to voice production.
  • the activating may include providing a current pulse having a duration of about 0.01 msec to 20 msec and a magnitude in the range of about 0.05 mA to 20 mA.
  • the stimulation parameter may include a stimulation frequency that is approximately reciprocal to a contraction time of a vocal cord adductor of the subject and may include a stimulation frequency that is above a reciprocal of a contraction time of a vocal cord abductor of the subject.
  • the stimulation parameter may include a stimulation voltage that is above a threshold for activation of vocal cord abductor or adductor muscles of the subject.
  • the stimulation parameter may include a stimulation voltage that is above a threshold for activation of vocal cord adductor muscles of the subject and below a threshold for activation of vocal cord abductor muscles of the subject.
  • the stimulation parameter may include a stimulation voltage that is above a threshold for activation of vocal cord abductor muscles of the subject and above a threshold for activation of vocal cord adductor muscles of the subject.
  • the stimulation parameter may include a stimulation voltage so that a net force for activation of adductor muscles is higher than a net force for activation of abductor muscles of the subject.
  • the method may further include determining when the voice activity has reached a predetermined level, and then having the sensing electrode generate the first signal when the predetermined level is reached.
  • a stimulation system for a human subject having unilateral vocal cord autoparalysis includes a manual activator configured to generate a first signal, a processor configured to receive the first signal and to generate at least one stimulation parameter based on the first signal, and a stimulating electrode configured to receive the stimulation parameter from the processor and to activate a glottic closure reflex of the subject based on the stimulation parameter.
  • the manual activator may be a switch operable by the subject.
  • the processor may be configured to receive the first signal by inductive coupling, capacitive coupling, electromagnetic transmission, light coupling, vibratory coupling, mechanical coupling and/or acoustical coupling.
  • a pacemaker system for a human subject having unilateral vocal cord autoparalysis includes a sensing electrode configured to detect voice activity of the subject and to generate a first signal and a processor in communication with the sensing electrode.
  • the processor has program code for receiving the first signal and for generating at least one stimulation parameter based on the first signal in order to activate a glottic closure reflex of the subject.
  • the system further includes a stimulating electrode configured to receive the stimulation parameter and to activate the glottic closure reflex of the subject based on the stimulation parameter.
  • the stimulating electrode may be a nerve cuff electrode and/or a rod electrode.
  • the stimulation electrode may be configured to provide a range of stimulation voltages.
  • the processor may be configured to detect when the first signal has reached a predetermined level and may be configured to generate the stimulation parameter when the predetermined level is reached.
  • the processor may detect when the first signal has reached a predetermined level and respond by generating the stimulation parameter. Additionally, the processor may include a pulse generator. In accordance with other related embodiments, the electrodes may be bipolar or tripolar. The second signal may be a biphasic current pulse which may have a duration of about 0.001 ms to 50 ms, in most subjects from 0.1 msec to 5 msec, and a magnitude in the range of about 0.05 mA to 20 mA, in most subjects from 0.5 mA to 5 mA.
  • the method may further include providing an energy coupling circuit that inductively couples energy through the skin of the subject.
  • the method may include providing an energy coupling circuit that optically couples energy through the skin of the subject.
  • Stimulating the vocalizing nerve of the subject with an electrical signal may include stimulating the nerve with an electrical signal at a frequency that is approximately reciprocal to the contraction time of the vocal cord adductor of the subject.
  • Stimulating the vocalizing nerve of the subject with an electrical signal may include stimulating the nerve with an electrical signal at a frequency that is above the reciprocal of the contraction time of the vocal cord abductor of the subject.
  • a reinnervated vocal cord may not be capable of abduction or adduction because the innervation is misdirected (a condition known as synkinetic innveration). Synkinetic innervation occurs when abductor fibers reach and reinnervate the adductor muscles and/or adductor fibers reach and reinnervate the abductor muscles.
  • the reinnervated vocal cord may not be capable of abduction and/or adduction because of a reduction in the number of re-innervated motor units, (sometimes associated with trophic changes of muscle fibers), disturbance of nerve conductivity, or less maturation of neuromuscular junctions.
  • Embodiments of the present invention recognized the benefit of treating unilateral vocal cord autoparalysis by stimulating the RLN or vagus nerve or by activating the glottic closure reflex by electrical and/or mechanical stimulation in order to selectively activate the abductor muscle, the adductor muscles or both.
  • the advantages of nerve stimulation or reflex activation over intramuscular stimulation are less interference of the stimulation electrode from movement of the muscle, the placement of the implanted electrode is distant from the risky, delicate location of nerve muscle endplates, less invasive surgery is required for implanting the stimulation electrode, etc.
  • the benefits of using embodiments of the present invention allow the opening and closing of the vocal folds to be activated by the same stimulation electrode based on the stimulation parameters selected due to the differences between the abductor (the opener) and the adductor (the closer) muscles (e.g., frequency-dependent, different thresholds or difference of net forces of adductor and abductor muscles). Exploiting these differences allows for a stimulation system that provides for the selective activation of vocal fold closing muscles, without activation of vocal fold opening muscles, the selective activation of vocal fold opening muscles, without activation of vocal fold closing muscles, and/or the tensioning of vocal folds by graded balanced activation of both opening and closing muscles.
  • Embodiments of the present description are directed to a system and method of sensing the vocal activity of a vocalizing muscle contraction in the larynx and/or pharynx and stimulation of the RLN or vagus nerve innervating a vocalizing muscle, e.g., without the electrical stimulation of the muscle fibers directly, based on the sensed activity.
  • the sensed vocalizing muscle is typically a synkinetically reinnervated dysfunctional muscle. This would allow the surgeon to choose the optimum accessibility to the nerve.
  • US Patent No. 5,111,814 by Goldfarb teaches sensing of electrical activity of normally functioning muscle tissue and stimulating of reinnervated muscle tissue of the larynx.
  • Embodiments of the present description are also directed to a system and method of sensing the vocal activity of a vocalizing muscle contraction in the larynx and/or pharynx and activating the glottic closure reflex.
  • This reflex may be activated by stimulation of a nerve, such as the superior laryngeal nerve, the internal or external superior nerve, and/or the glossopharyngeal nerve. It may also be elicited by stimulating mechanoreceptors and/or mucosa of the larynx and/or pharynx, or by the slap reflex. Stimulation may occur by electric currents and/or by mechanical movement or vibration. This variety of stimulation sites may allow a surgeon to choose the optimum treatment for the patient.
  • the glottic closure reflex activates the natural fiber tissue which innervates the vocalizing muscles that control the closure of the vocal folds.
  • stimulation of the RLN or vagus nerve and activation of the glottic closure reflex may be done at the same time.
  • the glottis is closed by active electrical sensing/stimulation or electrical sensing and electrical/mechanical stimulation in order to increase the quality of the voice.
  • US Patent No. 5,111,814 is employed to stimulate muscles which open the glottis in order to increase the amount of inspired air.
  • US Patent Publication No. 2006/282127 by Zealar is employed to open the vocal folds for the same reason.
  • embodiments of the present method and device are directed to the sensing activity of vocalizing muscle contraction and not respiratory muscle contraction as, e.g., in US Patent Publication No. 2006/282127 by Zealear .
  • a manual activator may be used instead of the active sensing of a vocalizing muscle contraction.
  • the manual activator then activates the RLN, the vagus nerve, or glottic closure reflex, e.g., by causing stimulation parameters to be sent to the appropriate locations via the stimulation electrode(s).
  • the manual activator allows the stimulation system to be inactive during periods in which vocalization would not be needed, e.g., during sleep or while eating, but allows it to be manually activated when vocalization is desired.
  • various stimulation parameters may be used in order to take advantage of the differences between the abductor (the opener) and the adductor (the closer) muscles in terms of the threshold voltage for activation, the contraction time, and the number of fibers.
  • the stimulation parameters include varying amplitude, frequency and/or threshold.
  • the applied voltage and the stimulation frequency may be chosen such that the desired muscles are activated.
  • the stimulation voltage should be directly proportional to the threshold values and the stimulation frequency indirectly proportional to the contraction times.
  • Embodiments of the present description may use the frequency-dependent movement of the vocal cords, as shown in FIG. 1 .
  • Such movement occurs as a result of the difference in contraction times between the abductor and adductor muscles.
  • the contraction time of the only existing abductor of the vocal cords, the posterior cricoarytenoid (PCA) muscle is significantly longer than that of the adductor muscles.
  • the RLN contains the nerve fibers to all muscles that act on the vocal cords (except the cricothyroid (CT) muscle which is innervated by the superior laryngeal nerve (SLN)), randomly distributed over the whole nerve. Consequently, an action potential generated by an electrical stimulation always reaches both abductor and adductor muscles.
  • CT cricothyroid
  • SSN superior laryngeal nerve
  • the action potentials When stimulated at a frequency approximately reciprocal to the contraction time of the vocal cord abductor, the action potentials arrive at the muscles at a time when the adductor muscles will have just relaxed from the last activation when the next pulse arrives (as shown below the zero-line on the graph).
  • the abductor in contrast, has just reached its maximal contraction when the incoming initiation for the next contraction causes their temporal summation (shown above the zero-line). Consequently, resulting tetanic abductor tension overcomes the weaker single twitch adduction.
  • the adductor muscles For stimulation at a frequency approximately reciprocal to the contraction time of the vocal cord adductor, the adductor muscles also reach tetanic contraction, and due to their greater number (4:1) the vocal cords are closed.
  • Embodiments of the present description may use the different thresholds for electrical activation for the nerves innervating the abductor and adductor muscles.
  • the threshold for activation for abduction is higher than the threshold for adduction because the contraction time of the PCA muscle is significantly longer than that of the adductor muscles. Therefore, the PCA muscle is innervated by nerve fibers of smaller mean nerve fiber diameter which have a threshold for electrical activation higher than for nerve fibers of higher mean nerve fiber diameter, such as innervating the adductor muscles.
  • the abductor muscle fibers When stimulated by a stimulation voltage above the threshold for activation of the nerve fibers innervating the adductor muscle but below the threshold for activation of the nerve fibers innervating the abductor muscle, the abductor muscle fibers will not be activated and therefore relaxed. In contrast, nerve fibers innervating the adductor muscle fibers will be activated, leading to a contraction of the adductor muscles, and the vocal cords will close.
  • the stimulation voltage is above the respective thresholds for activation for both abductor and adductor muscles, then both sets of muscles will be stimulated. The larger the stimulation amplitude (i.e., the injected amount of charge), the stronger both the abductor and adductor muscles are activated independent of the chosen stimulation frequency, provided the stimulation voltage is above each respective threshold.
  • Embodiments of the present description may use the difference of net forces of adductor and abductor muscles due to electrical activation for the nerves innervating the abductor and adductor muscles.
  • the net force for activation of adductor muscles is higher than the net force for activation of abductor muscles due to their greater number (4 adductor muscles versus 1 abductor muscle per side).
  • the abductory (vocal fold opening) net force of the abductor muscle fibers When stimulated by a stimulation voltage above the threshold for activation of the nerve fibers innervating the adductor muscles and above the threshold for activation of the nerve fibers innervating the abductor muscle, the abductory (vocal fold opening) net force of the abductor muscle fibers will be lower than the adductory (vocal fold closing) net force of the adductor muscle fibers, as a sum of forces leading to a closing of the vocal folds.
  • the stimulation parameters should be selected based on the desired application and selective activation.
  • the stimulation voltage when the stimulation voltage is below the threshold value for activation of the adductors, then no stimulation occurs regardless of the stimulation frequency or amplitude used.
  • the stimulation voltage is above the threshold value for activation of the adductors, but below the threshold value for activation of the abductors, then the vocal folds are closed, regardless of the stimulation frequency or amplitude used, which should benefit patients having unilateral vocal cord autoparalysis.
  • the vocal folds may be opened due to tetanic contraction of the abductor muscle when the stimulation frequency is approximately the stimulation frequency of the abductor muscle and the amplitude is low.
  • the vocal folds may be opening when these same conditions are applied (the stimulation voltage is above the threshold value for activation of the abductors and the stimulation frequency is approximately the stimulation frequency of the abductor muscle) but a high amplitude is used such that the force of tetanically contracted abductor muscle is greater than the twitch contractions of the adductor muscles.
  • the vocal folds may be closing (although there may be a ripple or vibration depending on the stimulation frequency) because the high applied amplitude overrules tetanic contraction of the abductor muscle.
  • the stimulation voltage is above the threshold value for activation of the abductors and the stimulation frequency is approximately the stimulation frequency of the adductor muscle, then the vocal folds are closed, regardless of the amplitude used, which should benefit patients having unilateral vocal cord autoparalysis.
  • a low amplitude may be less than approximately 1.5mA
  • a high amplitude may be about 1 to 3mA
  • a very high amplitude may be greater than about 2.5mA, for a pulse duration of about 0.5 ms.
  • the stimulation voltage may be switched between a voltage less than the stimulation voltage of the abductor muscle to a stimulation voltage greater than the stimulation voltage of the abductor muscle, which causes the vocal cords to switch between a closed and an open state.
  • the amplitude may be switched between a low value and a high value (or very high value), which causes the vocal cords to switch between an opened and an opening (or closing) state.
  • the stimulation frequency may be switched between the stimulation frequency of the abductor muscle and the adductor muscles, which causes the vocal cords to switch between an opened and a closed state.
  • Embodiments of the present description include stimulation electrode(s) that are configured to provide various stimulation voltages, frequencies and/or amplitudes, so that the various stimulation parameters may be implemented.
  • the synkinetically re-innervated nerve, and not the muscle directly, is stimulated because more than 10 times less power is necessary for activation of a nerve than of the muscle itself.
  • a nerve-cuff-electrode can be positioned along the nerve far from moving muscles and tissue and far from sensitive receptors, which would produce unwanted reactions.
  • FIG. 2 is a graphical illustration of the frequency-dependent motion of the vocal cords. Stimulation at 10 to 30 Hz causes a graded abduction 201 of the vocal cords. Above 30 Hz graded cord adduction occurs 202, with total airway occlusion 203 at 100 Hz by bilateral stimulation.
  • FIGS. 3 and 3A are illustrations of a stimulation system according to one embodiment of the present description.
  • a stimulation system for unilateral vocal cord autoparalysis includes one or more stimulating (efferent) electrodes 301 and one or more sensing (afferent) electrodes (not visible) or a manual activator that may be activated by the user, e.g., a switch or toggle, instead of, or in addition to, the sensing electrodes.
  • the stimulation system also includes a processor 303, which may include a pulse generator.
  • the processor 303 may be implanted in the patient's chest, and the stimulating electrodes 301 maybe wrapped around or placed near or in contact with the vagus nerve or RLN 302 along with the electrode leads 304 and safety loops 305.
  • the stimulation electrodes 301 may be used indirectly to stimulate the RLN or vagus nerve by activating the glottic closure reflex, by stimulation of a nerve, such as the superior laryngeal nerve, the internal or external superior nerve, and/or the glossopharyngeal nerve.
  • the stimulation electrodes 301 may be used to stimulate the glottic closure reflex by stimulating mechanoreceptors and/or mucosa of the larynx and/or pharynx, or by the slap reflex.
  • the stimulation may be electrical and/or mechanical or vibratory stimulation.
  • Embodiments of the present system may be totally or partially implanted in a human subject.
  • the stimulator may include a housing that can be very small with all of the implant's electronic components contained in a robust and compact hermetically sealed case. Energy and necessary information may be inductively or optically transferred through the skin of the subject. This can be achieved by either enclosing the electronic circuitry inside a metallic case with a secondary coil placed aside or around the case. Similarly, this may be achieved by enclosing the electric circuitry and a secondary coil inside a dielectric case.
  • the sensing (afferent) part of the closed loop system includes one or more sensing electrodes that detect the voice activities of the infrahyoidal muscles or signals recorded by the alternative sensors (step 101).
  • the sensing electrode(s) may be configured to detect electromyographic (EMG) activity of a vocalizing muscle and/or to detect movement related to voice production.
  • EMG electromyographic
  • the sensing electrode may be a microphone that detects acoustic signals related to voice production, an impedance sensor that detects changes of impedances related to voice production, and/or a pressure sensor that detects changes in pressure related to voice production.
  • the sensing electrode generates a first signal in response to the activity that has been detected.
  • the first signal is received (step 102) at a processor 303.
  • the processor 303 may include a pulse generator.
  • the processor 303 receives the first signal from the sensing electrode and generates at least one stimulation parameter (step 103) that is based on the first signal.
  • the stimulation parameter or second signal may be a biphase current pulse, and the biphase current pulse may have a duration of about 0.001 ms to 50 ms, in most subjects from about 0.1 msec to 5 msec, and a magnitude in the range of about 0.05 mA to 20 mA, in most subjects from about 0.5 mA to 5 mA.
  • the stimulation parameter from the processor 303 is received by one or more stimulating electrodes 301 (step 104), and the stimulating electrode(s) 301 stimulate a vocalizing nerve, such as the RLN or the vagus nerve directly (from which the RLN originates and which is easier to handle surgically), in accordance with the stimulation parameter.
  • the stimulating electrode(s) 301 may stimulate the RLN or the vagus nerve indirectly by activating the glottic closure reflex(es) (step 105), which then activate the RLN or vagus nerve.
  • the stimulation is limited to the time periods of voice production or swallowing or valsalva maneuver. Outside these activities, the synkinetic reinnervated vocal fold passively relaxes to the paramedian position.
  • the stimulating electrodes and the sensing electrodes may be either bipolar or tripolar. Similarly, one electrode may be bipolar and one electrode may be tripolar.
  • the electrode leads 304 should be sufficiently damage-resistant.
  • the lead body should be arranged in a way, so that the nerve and the stimulator are influenced as little as possible by movements of the muscles, the neck and the head.
  • Embodiments can be used to activate the vocal cord adduction in autoparalysis patients (where the adductor muscles are re-innervated but in a misdirected way) by stimulating the whole innervating RLN or alternatively, the vagus nerve, from which the RLN originates.
  • This treatment is effective with respect to autoparalysis patients because it is based on muscle characteristics and not on nerve or muscle/nerve characteristics only.
  • FIG. 5 is a flow chart illustrating a method of pacing laryngeal activity of a human subject in accordance with one embodiment.
  • Electrical activity of a vocalizing muscle (such as the infrahyoidal muscles) of a human subject is sensed (step 110), and a vocalizing nerve (such as the RLN or the vagus nerve) of the subject is directly stimulated with an electrical signal in synchronism with the sensed electrical activity.
  • the RLN or the vagus nerve may be indirectly stimulated by the activation of the glottic closure reflex(es) (step 120).
  • the stimulation/activation parameters may include stimulating the glottic closure reflex with an electrical signal at a stimulation frequency above the reciprocal value of the contraction time of the vocal cord adductor of the subject.
  • Stimulating the vocalizing nerve of the subject with an electrical signal may include stimulating the nerve with an electrical signal at a frequency approximately reciprocal to the contraction time of the vocal cord adductor of the subject and above the reciprocal of the contraction time of the vocal cord abductor of the subject.
  • FIG. 6 is a flow chart illustrating a method of pacing laryngeal activity of a human subject using a manual activator in accordance with one embodiment of the description.
  • the stimulation system is manually activated in step 130.
  • the manual activator may send a first signal to the processor 303, which may include a pulse generator.
  • the processor 303 receives the first signal from the manual activator and generates at least one stimulation parameter that is based on the first signal.
  • a glottic closure reflex is then activated (step 140) based on the stimulation parameter, which in turn stimulates the RLN or vagus nerve of the subject.
  • the stimulation may be electrical and/or mechanical or vibratory stimulation.
  • processor 303 may be implemented as hardware, software (e.g., a computer program product), or a combination of both software and hardware.
  • embodiments may be implemented as a computer program product for use with a computer system.
  • Such implementation may include a series of computer instructions or program code fixed either on a tangible medium, such as a computer readable medium (e.g., a diskette, CD-ROM, ROM, or fixed disk) or transmittable to a computer system, via a modem or other interface device, such as a communications adapter connected to a network over a medium.
  • the medium may be either a tangible medium (e.g., optical or analog communications lines) or a medium implemented with wireless techniques (e.g., microwave, infrared or other transmission techniques).
  • the series of computer instructions may embody all or part of the functionality previously described herein with respect to the processor.
  • Those skilled in the art should appreciate that such computer instructions may be written in a number of programming languages for use with many computer architectures or operating systems.
  • such instructions may be stored in any memory device, such as semiconductor, magnetic, optical or other memory devices, and may be transmitted using any communications technology, such as optical, infrared, microwave, or other transmission technologies.
  • It is expected that such a computer program product may be distributed as a removable medium with accompanying printed or electronic documentation (e.g., shrink wrapped software), preloaded with a computer system (e.g., on system ROM or fixed disk), or distributed from a server or electronic bulletin board over the network (e.g., the Internet or World Wide Web).

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Claims (15)

  1. Ein Schrittmachersystem für eine Person, die unilaterale Stimmbandautoparalyse hat, wobei das System folgendes umfasst:
    eine Messelektrode, die dazu eingerichtet ist, Sprachaktivität der Person zu detektieren und ein erstes Signal zu erzeugen;
    einen Prozessor (303), der mit der Messelektrode in Verbindung steht, wobei der Prozessor (303) einen Programmcode umfasst, zum Empfangen des ersten Signals und zum Erzeugen mindestens eines Stimulationsparameters basierend auf dem ersten Signal, um ein Glottisverschlussreflex der Person zu aktivieren; und
    eine oder mehrere Stimulationselektroden (301), die dazu eingerichtet sind, den mindestens einen Stimulationsparameter zu empfangen, und die dazu eingerichtet ist oder sind, einen rückläufigen Kehlkopfnerv oder den Vagus-Nerv zu stimulieren, und dazu eingerichtet ist oder sind, den Glottisverschlussreflex der Person gleichzeitig zu aktivieren, basierend auf dem mindestens einen Stimulationsparameter, um selektiv einen Stimmbandabduktormuskel und Stimmbandadduktormuskeln der Person zu aktivieren.
  2. System nach Anspruch 1, wobei die eine oder die mehreren Stimulationselektroden (301) eine Nervenmanschettenelektrode, eine Stabelektrode, oder Kombinationen davon sind.
  3. System nach Anspruch 1, wobei die eine oder die mehreren Stimulationselektroden (301) dazu eingerichtet sind, einen Bereich von Stimulationsspannungen bereitzustellen.
  4. System nach Anspruch 1, wobei der Prozessor (303) dazu eingerichtet ist, es zu detektieren, wenn das erste Signal eine vorbestimmte Schwelle erreicht hat, und dazu eingerichtet ist, den mindestens einen Stimulationsparameter zu erzeugen, wenn die vorbestimmte Schwelle erreicht ist.
  5. System nach Anspruch 1, wobei die eine oder die mehreren Stimulationselektroden (301) dazu verwendet werden, den Glottisverschlussreflex durch elektrische Stimulation, mechanische Stimulation oder eine Kombination davon zu aktivieren.
  6. System nach Anspruch 1, wobei die Messelektrode dazu eingerichtet ist, elektromyografische (EMG) Aktivität eines Stimmbandmuskels zu detektieren.
  7. System nach Anspruch 1, wobei die Messelektrode dazu eingerichtet ist, Bewegungen zu detektieren, die mit Stimmproduktion in Beziehung stehen.
  8. System nach Anspruch 1, wobei die Messelektrode ein Mikrofon ist, das akustische Signale detektiert, die mit Stimmproduktion in Beziehung stehen, oder
    wobei die Messelektrode ein Impedanzsensor ist, der Impedanzänderungen detektiert, die mit Stimmproduktion in Beziehung stehen, oder
    wobei die Messelektrode ein Drucksensor ist, der Druckänderungen detektiert, die mit Stimmproduktion in Beziehung stehen.
  9. System nach Anspruch 1, wobei der mindestens eine Stimulationsparameter ein Strompuls ist, der eine Dauer von ungefähr 0,01 ms bis 20 ms und eine Amplitude im Bereich von ungefähr 0,05 mA bis 20 mA hat.
  10. System nach Anspruch 1, wobei der mindestens eine Stimulationsparameter einen der folgenden Parameter umfasst:
    - eine Stimulationsfrequenz, die ungefähr dem Kehrwert einer Kontraktionszeit eines Stimmbandadduktors der Person entspricht, oder
    - eine Stimulationsfrequenz, die größer als ein Kehrwert einer Kontraktionszeit eines Stimmbandabduktors der Person ist, oder
    - eine Stimulationsspannung, die über einer Aktivierungsschwelle von Stimmbandabduktormuskeln der Person liegt, oder
    - eine Stimulationsspannung, die über einer Aktivierungsschwelle von Stimmbandadduktormuskeln der Person liegt, oder
    - eine Stimulationsspannung, die über einer Aktivierungsschwelle von Stimmbandadduktormuskeln der Person und unter einer Aktivierungsschwelle von Stimmbandabduktormuskeln der Person liegt, oder
    - eine Stimulationsspannung, die über einer Aktivierungsschwelle von Stimmbandabduktormuskeln der Person und über einer Aktivierungsschwelle von Stimmbandadduktormuskeln der Person liegt.
  11. System nach Anspruch 1, wobei der Stimulationsparameter eine Stimulationsspannung umfasst, sodass eine Nettokraft zur Aktivierung von Adduktormuskeln höher als eine Nettokraft zur Aktivierung von Abduktormuskeln der Person ist.
  12. System nach Anspruch 1, wobei das System dazu eingerichtet ist, zu bestimmen, wann die Stimmaktivität eine vorbestimmte Schwelle erreicht hat, wobei die Messelektrode dazu eingerichtet ist, mit der Erzeugung des ersten Signals zu reagieren, wenn die vorbestimmte Schwelle erreicht ist.
  13. Stimulationssystem für eine Person, die unilaterale Stimmbandautoparalyse hat, wobei das System folgendes umfasst:
    einen manuellen Aktivator, der dazu eingerichtet ist, ein erstes Signal zu erzeugen;
    einen Prozessor (303), der dazu eingerichtet ist, das erste Signal zu empfangen und mindestens einen Stimulationsparameter zu erzeugen, wobei der Stimulationsparameter auf dem ersten Signal basiert; und
    eine oder mehrere Stimulationselektroden (301), die dazu eingerichtet sind, den mindestens einen Stimulationsparameter von dem Prozessor (303) zu empfangen, und dazu eingerichtet sind, den rückläufigen Kehlkopfnerv oder den Vagus-Nerv zu stimulieren, und dazu eingerichtet ist oder sind, einen Glottisverschlussreflex der Person gleichzeitig zu aktivieren, basierend auf dem mindestens einen Stimulationsparameter, um selektiv einen Stimmbandabduktormuskel und Stimmbandadduktormuskeln der Person zu aktivieren.
  14. System nach Anspruch 13, wobei der manuelle Aktivator ein Schalter ist, der von der Person betrieben werden kann.
  15. System nach Anspruch 13, wobei der Prozessor (303) dazu eingerichtet ist, das erste Signal durch Induktionskopplung, Kapazitätskopplung, elektromagnetische Übertragung, Lichtkopplung, Vibrationskopplung, mechanische Kopplung, akustische Kopplung oder Kombinationen davon zu empfangen.
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US20130150924A1 (en) 2013-06-13
AU2012347584B2 (en) 2015-07-09
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AU2012347519B2 (en) 2015-06-11
US20130150926A1 (en) 2013-06-13
US9731123B2 (en) 2017-08-15
AU2012347510A1 (en) 2014-07-24
CN103998096A (zh) 2014-08-20
CN103987424A (zh) 2014-08-13
EP2788076B1 (de) 2018-04-25
WO2013086392A1 (en) 2013-06-13
CA2858190C (en) 2018-11-06
EP2788076A1 (de) 2014-10-15
CN104080511B (zh) 2016-06-29
EP3348305A1 (de) 2018-07-18
EP2788082A1 (de) 2014-10-15
WO2013086421A1 (en) 2013-06-13
AU2012347510B2 (en) 2015-09-17
EP2788083B1 (de) 2021-06-02
US20150246228A1 (en) 2015-09-03
CA2858190A1 (en) 2013-06-13
AU2012347584A1 (en) 2014-07-03
CN103998096B (zh) 2016-06-15
US9026204B2 (en) 2015-05-05
AU2012347519A1 (en) 2014-06-12
US9050462B2 (en) 2015-06-09
CA2858098A1 (en) 2013-06-13
EP2788082B1 (de) 2019-02-20
EP2788083A4 (de) 2015-11-04
EP2788076A4 (de) 2015-12-23
CN103987424B (zh) 2016-05-18
US20130150908A1 (en) 2013-06-13
US8731683B2 (en) 2014-05-20
EP2788082A4 (de) 2015-08-05
CA2858098C (en) 2018-03-27
WO2013086412A1 (en) 2013-06-13

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